Attitudes Toward and Use of Prostate-Specific Antigen Testing Among Urologists and General Practitioners in Germany: A Survey.

BACKGROUND: In 2020, around 1.4 million new prostate cancer (PCa) cases were recorded worldwide. Early detection of PCa by prostate-specific antigen (PSA) screening remains debated, leading to different specialist-specific recommendations in PCa guidelines. This study aimed to assess attitudes toward and use of PSA testing among urologists in Germany and general practitioners (GPs) in Lower Saxony (Germany). METHODS: A nationwide questionnaire was sent to urologists via the mailing lists of the Professional Association of German Urologists and the German Urological Society. A version of the questionnaire for GPs was sent to email addresses via the Association of Statutory Health Insurance Physicians Lower Saxony. The online questionnaires covered use of PSA testing, information communication, handling of test results, and handling of/knowledge about national and international guidelines and recommendations on early detection of PCa. Statistical analysis was performed at a descriptive level. RESULTS: In total, 432 of 6,568 urologists (6.6%) and 96 of 1,579 GPs (6.1%) participated in this survey. Urologists and GPs differed in their attitudes and approaches toward PSA testing. Most urologists (86.8%, n=375) judged the test as "very meaningful" or "meaningful", compared with 52.1% (n=50) of GPs. Almost two-thirds of the urologists (64.4%, n=278) viewed the PCa mortality reduction by PSA testing as proven, compared with one-fifth of GPs (20.8%, n=20). Almost 80% of male urologists (79.9%, n=291) indicated that they would undergo a PSA test in the future (again), compared with 55.1% of male GPs (n=38). In addition, 56.3% (n=243) of urologists stated that "considerably more than half" or "almost all" men aged 45 years or older received a PSA test, compared with 19.8% (n=19) of GPs. CONCLUSIONS: Urologists are more convinced about the PSA test than GPs. PSA testing is therefore used more often in urological settings, although the preselected patient population must be considered. In accordance with specialist-specific recommendations, GPs show a more reserved approach toward PSA testing. Instead of focusing on different attitudes and recommendations on PSA testing, the exchange between specialist groups should be improved to achieve a consistent approach to PSA testing.

General practitioners' approaches to prostate-specific antigen testing in the north-east of the Netherlands.

BACKGROUND: There is wide variation in clinical practice for the early detection of prostate cancer, not least because of the ongoing debate about the benefits of prostate-specific antigen (PSA) testing. In this study, we aimed to assess the approaches, attitudes, and knowledge of general practitioners (GPs) regarding PSA testing in primary care in the Netherlands, particularly regarding recommendations for prostate cancer. METHODS: Questionnaire surveys were sent to 179 GPs in the north-east of the Netherlands, of which 65 (36%) were completed and returned. We also surveyed 23 GPs attending a postgraduate train-the-trainer day (100%). In addition to demographic data and practice characteristics, the 31-item questionnaire covered the attitudes, clinical practice, adherence to PSA screening recommendations, and knowledge concerning the recommendations for prostate cancer early detection. Statistical analysis was limited to the descriptive level. RESULTS: Most GPs (95%; n = 82) stated that they had at least read the Dutch GP guideline, but just half (50%; n = 43) also stated that they knew the content. Almost half (46%; n = 39) stated they would offer detailed counseling before ordering a PSA test to an asymptomatic man requesting a test. Overall, prostate cancer screening was reported to be of minor importance compared to other types of cancer screening. CONCLUSIONS: Clinical PSA testing in primary care in this region of the Netherlands seems generally to be consistent with the relevant guideline for Dutch GPs that is restrictive to PSA testing. The next step will be to further evaluate the effects of the several PSA testing strategies.

Early detection of prostate cancer using prostate-specific antigen testing: an empirical evaluation among general practitioners and urologists.

Background: Prostate cancer (PCa) is the most frequent cancer and the third leading cause of cancer death among German men. One option for PCa early detection is prostate-specific antigen (PSA) testing, which is still under debate regarding its risk benefits. Besides recommendations on the early PCa detection, daily practice on PSA testing varies in, for example, information communication and usage of the test. This pilot study assessed potential differences between general practitioners (GPs) and urologists in handling PSA testing and guidelines on early detection of PCa. Methods: 172 GPs belonging to the teaching network of the University of Oldenburg in Lower Saxony and Bremen and 128 practicing urologists were included in the online survey focusing on PSA testing. The questionnaire covered 43 questions on topics as the usage of the test, information communication, handling of test results and handling of/knowledge about national and international guidelines on PCa. Wether PSA testing is used in accordance with guidelines was also explored in four standardized case scenarios. Statistical analysis was done at a descriptive level. Results: In total, 65 doctors participated in the survey (response proportion: 21.7%, n=65; 27.9%, n=48 [GPs]; 13.2%, n=17 [urologists]). Results of 41 GPs and 14 urologists were analyzed. The PSA test was judged as useful by all urologists, while almost half of the GPs valued the test as ambivalent or not useful. Urologists showed a more proactive approach of informing men on PSA testing. Regarding guidelines and recommendations on PSA testing, GPs were less familiar with them compared to the urologists. Doctors of both specialties did not always treat men in consistence with the guidelines. This was partially in contradiction to their self-appraisal. Conclusion: This pilot study is highlighting differences in PSA testing practices between GPs and urologists in Germany. Urologists showed a more proactive approach. For further verification, we plan a more comprehensive study covering several German states.

Sequential tests for monitoring methods to detect elevated incidence - a simulation study.

BACKGROUND: Common cancer monitoring practice is seldom prospective and rather driven by public requests. This study aims to assess the performance of a recently developed prospective cancer monitoring method and the statistical tools used, in particular the sequential probability ratio test in regard to specificity, sensitivity, observation time and heterogeneity of size of the geographical unit. METHODS: A simulation study based on a predefined selection of cancer types, geographical unit and time period was set up. Based on the population structure of Lower Saxony the mean number of cases of three diagnoses were randomly assigned to the geographical units during 2008-2012. A two-stage monitoring procedure was then executed considering the standardized incidence ratio and sequential probability ratio test. Scenarios were constructed differing by the simulation of clusters, significance level and test parameter indicating a risk to be elevated. RESULTS: Performance strongly depended on the choice of the test parameter. If the expected numbers of cases were low, the significance level was not fully exhausted. Hence, the number of false positives was lower than the chosen significance level suggested, leading to a high specificity. Sensitivity increased with the expected number of cases and the amount of risk and decreased with the size of the geographical unit. CONCLUSIONS: The procedure showed some desirable properties and is ready to use for a few settings but demands adjustments for others. Future work might consider refinements of the geographical structure. Inhomogeneous unit size could be addressed by a flexible choice of the test parameter related to the observation time.

Using lung cancer mortality to indirectly approximate smoking patterns in space.

Smoking is the leading cause of lung cancer. Non-smoking factors have been associated with the disease. Existing Swiss survey data only capture the country partially and temporal coverage does not allow for a time lag between exposure to tobacco and lung cancer outbreak. Knowledge about the distribution of tobacco-use is essential to estimate its contribution to disease burden. Bayesian regression models were applied to estimate spatial smoking patterns. Data were provided from the Swiss Health Survey (14521 participants). Regression models with spatial random effects (SREs) were employed to obtain smoking proxies based on mortality rates and SREs adjusted for environmental exposures. Population attributable fractions were estimated to assess the burden of tobacco-use on lung cancer mortality. Correlation between observed smoking prevalence with smoking proxies was moderate and stronger in females. In the absence of sufficient survey data, smooth unadjusted mortality rates can be used to assess smoking patterns in Switzerland.

A Bayesian generalized age-period-cohort power model for cancer projections.

Age-period-cohort (APC) models are the state of art in cancer projections, assessing past and recent trends and extrapolating mortality or incidence data into the future. Nordpred is a well-established software, assuming a Poisson distribution for the counts and a log-link or power-link function with fixed power; however, its predictive performance is poor for sparse data. Bayesian models with log-link function have been applied, but they can lead to extreme estimates. In this paper, we address criticisms of the aforementioned models by providing Bayesian formulations based on a power-link and develop a generalized APC power-link model, which assumes a random rather than fixed power parameter. In addition, a power model with a fixed power parameter of five was formulated in the Bayesian framework. The predictive performance of the new models was evaluated on Swiss lung cancer mortality data using model-based estimates of observed periods. Results indicated that the generalized APC power-link model provides best estimates for male and female lung cancer mortality. The gender-specific models were further applied to project lung cancer mortality in Switzerland during the periods 2009-2013 and 2014-2018.

Bayesian spatio-temporal modelling of tobacco-related cancer mortality in Switzerland.

Tobacco smoking is a main cause of disease in Switzerland; lung cancer being the most common cancer mortality in men and the second most common in women. Although disease-specific mortality is decreasing in men, it is steadily increasing in women. The four language regions in this country might play a role in this context as they are influenced in different ways by the cultural and social behaviour of neighbouring countries. Bayesian hierarchical spatio-temporal, negative binomial models were fitted on subgroup-specific death rates indirectly standardized by national references to explore age- and gender-specific spatio-temporal patterns of mortality due to lung cancer and other tobacco-related cancers in Switzerland for the time period 1969-2002. Differences influenced by linguistic region and life in rural or urban areas were also accounted for. Male lung cancer mortality was found to be rather homogeneous in space, whereas women were confirmed to be more affected in urban regions. Compared to the German-speaking part, female mortality was higher in the French-speaking part of the country, a result contradicting other reports of similar comparisons between France and Germany. The spatio-temporal patterns of mortality were similar for lung cancer and other tobacco-related cancers. The estimated mortality maps can support the planning in health care services and evaluation of a national tobacco control programme. Better understanding of spatial and temporal variation of cancer of the lung and other tobacco-related cancers may help in allocating resources for more effective screening, diagnosis and therapy. The methodology can be applied to similar studies in other settings.

Tobacco-related cancer mortality: projections for different geographical regions in Switzerland.

PRINCIPLES: Switzerland is divided into 26 cantons of variable population size and cultural characteristics. Although a federal law to protect against passive smoking and a national tobacco control programme exist, details of tobacco-related policies are canton-specific. This study aimed to project gender-specific tobacco-related cancer mortality in Switzerland at different geographical levels for the periods 2009-2013 and 2014-2018. METHODS: In this analysis, data on Swiss tobacco-related cancer mortality from 1984 until 2008 were used. Bayesian age-period-cohort models were formulated to assess past trends of gender-specific tobacco-related cancer mortality and to project them up to 2018 at cantonal and language region levels. Furthermore, estimates are provided on a national scale by age categories of 50-69 and ≥70 years. RESULTS: Model-based estimates at cantonal level identified regions with low and high tobacco-related cancer mortality rates for the observed and projected periods. Our analysis based on language regions showed the lowest mortality in the German-speaking part. Projections at national level, between younger (age 50-69) and older (age ≥70) males, indicated an ongoing decreasing trend for males but an upward trend for females. The gap in tobacco-related cancer mortality rates between younger and older males seems to be shrinking. In females, a stronger rise was obtained for the younger age group. CONCLUSION: Our findings indicate region-, sex- and age-related differences in tobacco-related cancer mortality in Switzerland and this could be useful for healthcare planning and for evaluating the impact of canton-specific tobacco-related policies and interventions.